Male sexual dysfunction

Penile erection is a complex phenomenon which implies a delicate and coordinated equilibrium among the neurological, vascular and the smooth muscle compartment. It includes arterial dilation, trabecular smooth muscle relaxation and activation of the corporeal veno-occlusive mechanism. Erectile Dysfunction is defined as the persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance. Erectile Dysfunction may affect physical and psychosocial health and may have a significant impact on the quality of life (QoL) of sufferers and their partner’s. There is increasing evidence that ED can be an early manifestation of coronary artery and peripheral vascular disease. Erectile Dysfunction should not be regarded only as a QoL issue, but also as a potential warning sign of cardiovascular disease (CVD).

Risk Factors

Erectile Dysfunction shares both unmodifiable and modifiable common risk factors with CVD (e.g., obesity, diabetes mellitus, dyslipidemia, metabolic syndrome, lack of exercise, and smoking). The association between ED status and age, diabetes mellitus duration, poor glycemic control, body mass index (BMI), obstructive sleep apnea, hyperhomocysteinemia and chronic liver failure associated with hepatitis B has also been confirmed. An association between ED status and vitamin D deficiency has also been reported.

Treatments

Lifestyle management of ED with concomitant risk factors

The basic work-up of the patient must identify reversible risk factors for ED. Lifestyle changes and risk factor modification must precede or accompany any physical or/and pharmacological treatment. Major clinical potential benefits of lifestyle changes may be achieved in men with specific comorbid cardiovascular or metabolic disorders, such as diabetes or hypertension.

Use of pro-erectile drugs

Use of pro-erectile drugs following radical prostatectomy (RP) is important in achieving post-operative erectile function. Several trials have shown higher rates of erectile function recovery after RP in patients receiving any drug (therapeutic or prophylactic) for ED. Early compared with delayed erectile function treatment seems to impact on the natural recovery time for potency, although there is a lack of data to support any specific regimen for penile rehabilitation.

Hormonal therapy

The advice of an endocrinologist may be beneficial for managing patients with hormonal abnormalities. Testosterone deficiency is either a result of primary testicular failure or secondary to pituitary/hypothalamic causes (e.g. a functional pituitary tumor resulting in hyperprolactinaemia). When clinically indicated, testosterone supplementation (TS) (intramuscular, oral, or transdermal) is effective, but should only be used after other endocrinological causes for testicular failure have been excluded. Before initiating TS, digital rectal examination (DRE), serum PSA, hematocrit, liver function tests and lipid profile should be performed. Patients who are given TS should be monitored for a clinical response, elevation of hematocrit and development of hepatic or prostatic disorders.

Psychosexual counselling and therapy

For patients with a significant psychological problem, psychosexual therapy may be given either alone or with another therapeutic approach in order to improve couple sexual satisfaction and female sexual function. Psychosexual therapy requires ongoing follow-up and has had variable results.

Vacuum erection devices

Vacuum erection devices (VED) provide passive engorgement of the corpora cavernosa, together with a constrictor ring placed at the base of the penis to retain blood within the corpora. Published data report that efficacy, in terms of erections satisfactory for intercourse, is as high as 90%, regardless of the cause of ED and satisfaction rates range between 27% and 94% =. Most men who discontinue use of VEDs do so within three months. Long-term use of VEDs decreases to 50-64% after two years. The most common adverse events include pain, inability to ejaculate, petechiae, bruising, and numbness, which occur in < 30% of patients. Serious adverse events (skin necrosis) can be avoided if patients remove the constriction ring within 30 minutes after intercourse. Vacuum erection devices are contraindicated in patients with bleeding disorders or on anticoagulant therapy. Vacuum erection devices may be the treatment of choice in well-informed older patients with infrequent sexual intercourse and comorbidity requiring non-invasive, drug-free management of ED.

Shockwave therapy

The use of low-intensity extracorporeal shockwave therapy (LI-SWT) has been increasingly proposed as a treatment for ED over the last decade. Overall, most of these studies reported encouraging results, regardless of variation in LI-SWT set-up parameters or treatment protocols. As a whole these studies suggest that LI-SWT could significantly improve the IIEF and Erection Hardness Score of mild ED patients.

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